Full Prevention Statement

A Joint Statement on Prevention

Published by Edinburgh Community Health Forum, Health and Social Care Alliance Scotland (the ALLIANCE), Scottish Community Development Centre, and Voluntary Health Scotland.

As a partnership of national and local third and community sector intermediaries and organisations, we have come together in the spirit of collaboration to issue this joint statement on prevention.   

Scotland’s persistent and growing health inequalities affect people across the population.  At a time when healthy life expectancy has fallen to a ten-year low, the need for collective action is more urgent than ever before. 

We welcome the recent publication of three key documents that, together, set out a renewed national policy on prevention: the Public Service Reform Strategy, the Population Health Framework, and the Health and Social Care Service Renewal Framework.  The third and community sector played an important role in developing these documents, informed by our experience of working with and in communities living with the unfair and avoidable consequences of health inequalities. 

We wish to make clear, that this statement is not intended as a vehicle for influencing party political pledges ahead of the Scottish Parliament election next year.  Our intended audience is decision makers at local and national levels, and stakeholders supporting policy implementation like Public Health Scotland.  Our aim is to share our vision for prevention and recommendations for turning ambitious policy intent into action. 

Firstly, we believe a clear, specific, and consistently applied definition of prevention work in and with communities should be a priority. 

 As our members and networks regularly tell us, a lack of clarity on what ‘prevention’ means, and confusion on what constitutes prevention activity in a community setting, too often results in unnecessary obstacles to achieving sustainable outcomes.  We welcome that this is also acknowledged in the Population Health Framework, which notes (p13): “When people and organisations talk about prevention, they often use the same language to talk about different things.  This is a barrier to investing in the full range of prevention needed to improve the health and wellbeing of the people of Scotland.”

 We support the broad definition (p18) in the Public Sector Reform Strategy that prevention, “means stopping (preventing) the establishment, or escalation, of problems that lead to negative outcomes for people.” Preventing any form of inequality, including health inequalities, is about stopping issues being created and averting ill-health in the first place.  This means identifying and tackling root causes before negative outcomes occur.

In terms of a more detailed definition, we agree with Scottish Government and COSLA that as set out in the Public Health Framework, Public Health Scotland’s ‘public health approach to prevention’ – which includes the three levels of primary, secondary, and tertiary prevention – can provide a “common language for partners within...the wider system.”  This is further reinforced in the Population Health Framework and Public Service Reform Strategy – and we strongly endorse this position – that the public health approach to prevention can – and must – be applied system-wide.

We also believe that identifying what prevention is NOT can help common understanding, increase clarity in decision-making, and support partnership working in, and with, communities to build health and wellbeing. 

For example, while both are important, prevention should not be conflated with early intervention (stopping a problem in its early stages from getting worse) and, in the public health approach, primary prevention should not be conflated with secondary prevention. 

Our network members undertake work in, and with, communities which addresses health inequalities and is usually person-centred and community-led. This includes a broad range of primary, secondary preventative, early intervention and tertiary preventative work which covers multiple policy and service delivery areas.

Work that is needs-led, rights-based, and which contributes to building the health, wellbeing and resilience of individuals and communities is complex.  For example, individuals may participate in activities classed as primary prevention whilst also accessing services classed as early intervention and/or tertiary prevention/mitigation. Therefore, clarity and consistency in definition and application across all policy and practice areas is essential to aid resource allocation, impact measurement and prevention policy implementation that works across siloes and makes a positive difference to people’s lives.

Third and community sector organisations routinely gather evidence of our positive contribution to prevention and tackling health inequalities in, and with, communities. This often includes the views and experiences of people with lived and living experience who access or benefit from our work. However, a lack of consistency in reporting frameworks and systems at a local level means that this information is not always accessible, used or accepted as robust enough to those making strategic decisions about local resource allocation.

The experience of practitioners and organisations in our networks is that at an operational level the word prevention is increasingly being used to mean preventing additional public spend or preventing pressure on acute services, rather than preventing the onset or escalation of ill health.  This includes requirements to evidence how third sector work avoids individuals accessing acute services or reduces the numbers of unplanned hospital admissions.

This focus on the impact on acute/secondary services devalues and deprioritises activity which has a longer term, primary, secondary and tertiary prevention focus, and the positive impacts on individuals and communities. Local strategic partnerships in our networks also report that asking individual organisations and groups to prove or evidence the output or outcome of their specific interventions increases siloes and competition, rather than fostering partnership and collaboration.  

We appreciate the proposals for policy implementation set out in the Public Service Reform Strategy, Population Health Framework, and Health and Social Care Service Renewal Framework. We also warmly welcome the repeated recognition of – and value placed on – the third and community sector’s contribution to prevention and the importance of working alongside communities. 

We believe it is extremely important to explicitly acknowledge that implementing prevention policy in a rights-based way may mean doing things that some stakeholders find very difficult, for a range of cultural and practical reasons.  As demonstrated by previous attempts to put policy into practice, if these difficulties are not intentionally addressed, the result is an ever-widening implementation gap. Audit Scotland has consistently highlighted (p39-40) across multiple publications (p29) the need for greater transparency and accountability in the implementation of prevention across public sector bodies.

Some actions that are essential to policy implementation, but which can be difficult to achieve include:

• co-production and power-sharing with people, communities and the third sector;

• long-term investment and work;

• transparency and accountability;

• courageous leadership;

• evidence-gathering; and

• collaboration and integration across siloes and sectors (including fiscal). 

These things also take time, skills, and resources, which feel increasingly in short supply. 

Unfortunately, in an increasingly fraught public finance environment, work undertaken in, and with, communities and by the third and community sector is too often the ‘low hanging fruit’ that is first in line for cuts.

It is vital that all stakeholders charged with implementing prevention policy – and particularly those with most power and financial controls, like local and national government, and public sector bodies – engage in good faith and directly share their power and resources, as advocated for in the Population Health Framework.

Prevention is complex and cannot be achieved by one sector alone. A whole system approach must include the third and community sector, and those who directly experience health inequalities, as equal partners.  

Appendix 1 sets out a range of good practice examples of work from across our members and networks that demonstrates primary, secondary and tertiary prevention in and with communities. We urge decision-makers to focus first and foremost on building on, and learning from, existing good quality and effective work. 

We have come together to make this statement now because we are concerned that the preventative work of many community-led and third sector organisations – as well as that delivered by the public sector – may not survive into the next financial year.

Without immediate action we risk losing the groups, organisations and practitioners with the skills, experience and capacity to implement prevention policy effectively.

This joint statement addresses three things we believe are needed to achieve rights based, system-wide prevention:  

•  a clear, specific, and consistently applied definition of prevention;

• an intentional approach to addressing the ‘hard to do’ elements of policy implementation; and

• a sustainably resourced third and community sector that is treated as an equal partner in decision making with a public sector committed to working in, and with, communities

We welcome the renewed prevention policy intent from Scottish Government and COSLA but would stress it is now crucial this is translated – without delay – into specific, fully resourced, and measurable actions at the national and local levels.

We call for an approach that honestly and courageously acknowledges the precarious state of our public, third and community sectors and explicitly addresses the more challenging elements like investing in – and sharing power with – the third and community sector, and most importantly the individuals and communities experiencing the real life, day to day impact of poverty and health inequalities. 

A Joint Statement by: 

• Edinburgh Community Health Forum 

• Health and Social Care Alliance Scotland (the ALLIANCE) 

• Scottish Community Development Centre: Community Health Exchange 

• Voluntary Health Scotland